Older Americans Act: The National Eldercare Campaign (Letter Report, 02/23/94, GAO/PEMD-94-7). In April 1991, the Administration on Aging (AOA) launched a multiyear initiative called the National Eldercare Campaign. AOA used about $14 million of $26 million in title IV discretionary funds to support the campaign's various components. The largest portion of these funds went to a new community outreach effort, Project CARE. Under this national coalition-building demonstration program, each state was required to establish three local coalitions. At the end of 15 months, virtually all states had three local coalitions in place. A majority of coalitions had generated some resources, and about 70 percent of the coalitions were providing a service to the elderly. The campaign differs from earlier AOA initiatives in that its seeks to expand not only the Aging Network but also the resources available to them. Usually, AOA initiatives were of 12- to 24-months duration and limited to research, demonstration, and technical assistance. By the end of fiscal year 1992, about 200 coalitions had joined the Aging Network and had developed programs and services for the elderly. Although this is a significant change in both the mission and structure of the Aging Network, the success of this campaign ultimately depends upon the coalitions' ability to sustain themselves beyond the three-year funding period. --------------------------- Indexing Terms ----------------------------- REPORTNUM: PEMD-94-7 TITLE: Older Americans Act: The National Eldercare Campaign DATE: 02/23/94 SUBJECT: Elder care Federal/state relations Elderly persons Agency missions Aid for the elderly Public assistance programs Technical assistance State-administered programs IDENTIFIER: AOA National Eldercare Campaign AOA Aging Network AOA Project CARE Medicaid Program AOA Eldercare Connections Project AOA Eldercare Locator Project ************************************************************************** * This file contains an ASCII representation of the text of a GAO * * report. Delineations within the text indicating chapter titles, * * headings, and bullets are preserved. Major divisions and subdivisions * * of the text, such as Chapters, Sections, and Appendixes, are * * identified by double and single lines. The numbers on the right end * * of these lines indicate the position of each of the subsections in the * * document outline. These numbers do NOT correspond with the page * * numbers of the printed product. * * * * No attempt has been made to display graphic images, although figure * * captions are reproduced. Tables are included, but may not resemble * * those in the printed version. * * * * A printed copy of this report may be obtained from the GAO Document * * Distribution Facility by calling (202) 512-6000, by faxing your * * request to (301) 258-4066, or by writing to P.O. Box 6015, * * Gaithersburg, MD 20884-6015. We are unable to accept electronic orders * * for printed documents at this time. * ************************************************************************** Cover ================================================================ COVER Report to the Chairman, Subcommittee on Human Resources, Committee on Education and Labor, House of Representatives February 1994 OLDER AMERICANS ACT - THE NATIONAL ELDERCARE CAMPAIGN GAO/PEMD-94-7 A Description of the National Eldercare Campaign Abbreviations =============================================================== ABBREV AOA - Administration on Aging CARE - Community Action to Reach the Elderly OAA - Older Americans Act Letter =============================================================== LETTER B-254985 February 23, 1994 The Honorable Matthew G. Martinez Chairman, Subcommittee on Human Resources Committee on Education and Labor House of Representatives Dear Mr. Chairman: In your letter of July 16, 1992, you requested that we address a series of questions about the National Eldercare Campaign, a multiyear initiative being funded by the Administration on Aging (AOA). In response, this report examines the three questions: (1) What is the National Eldercare Campaign? (2) What has been the progress, thus far, in implementing the Campaign? and (3) What changes in the Aging Network as a result of the Campaign are discernible at this time? RESULTS IN BRIEF ------------------------------------------------------------ Letter :1 In April 1991, AOA launched a multiyear initiative, called the National Eldercare Campaign, drawing heavily on AOA title IV discretionary funds to strengthen the existing Aging Network by broadening the base of support and increasing public awareness.\1 AOA used about $14 million of almost $26 million title IV discretionary funds to support the various components and activities of the National Eldercare Campaign (see table 1). The largest amount of these funds was allocated to a new community outreach effort, Project CARE (Community Action to Reach the Elderly), which is a national coalition-building demonstration program. Each state was required to establish three local coalitions. Even though additional monies were not available to establish optional statewide coalitions, 32 state units did so. Additional monies were available to establish volunteer corps activities, and 30 state units did so. At the end of 15 months, virtually all states had three local coalitions in place. A majority of coalitions had generated some resources. Seven out of ten of the coalitions (107 of 151) were providing a service to elderly persons. We found that the Campaign, particularly its Project CARE component, is different from earlier initiatives fostered by AOA in that it is targeted to expand not only the Aging Network, but also the resources available to them. Usually, AOA initiatives were of 12- to 24-months' duration and limited to research, demonstration, and technical assistance. By the end of fiscal year 1992, about 200 coalitions had become part of the Aging Network, and they have developed programs and services for older individuals. This, then, is a significant change in both the mission and the structure of the Aging Network. However, it is important to note that the ultimate measure of the success of this Campaign depends upon the coalitions' ability to sustain themselves beyond the 3 years' funding. Table 1 Funding for the National Eldercare Campaign for Fiscal Year 1992 Component Amount\a -------------------------------------------------- -------- Project CARE $4.80 Public awareness 0.76 Outreach to national organizations 1.27 Other 7.17\b ============================================================ Total $14.00 ------------------------------------------------------------ \a In millions. \b The category "Other" includes the National Eldercare Institutes ($3.55 million), a contract with a private firm assisting AOA with logistics (Empire, $1.1 million), the optional Volunteer Corps Program ($0.9 million), special smaller activities in selected locations ($1.47 million), and dissemination within the Aging Network ($0.15 million). -------------------- \1 This network consists of 10 federal regional offices, 57 state units and 670 area agencies (substate units) on aging, and nearly 25,000 local service providers. The Aging Network, as an organization, has been instrumental in developing and delivering social, nutritional, and other services to the elderly. OBJECTIVES, SCOPE, AND METHODOLOGY ------------------------------------------------------------ Letter :2 Much of this report is based on our survey of officials from state units on aging in all 50 states, regarding Campaign operation and activities from October 1991 to December 1992 (the first 15 months of Campaign awards). Some of the data were collected on a calendar-year basis; some on a fiscal-year basis. Our survey was conducted between March 4, 1993, and April 21, 1993, and we had a 100-percent response rate. In addition, we collected information from: (1) 14 site visits of area agencies on aging and local coalitions as well as visits to 4 state units on aging; (2) directors of each of the 13 National Eldercare Institutes; (3) officials in the AOA central office, regional offices, state units, and area agencies, as well as experts on aging issues nationwide; and (4) a review of AOA agency documentation. We performed our work between September 1992 and September 1993, in accordance with generally accepted government auditing standards. BACKGROUND ------------------------------------------------------------ Letter :3 The Older Americans Act (OAA) of 1965 was established to provide assistance by developing a set of programs to support the nation's elderly (all persons 60 and over). Over the years, amendments to the act have greatly expanded the mission of AOA and the Aging Network beyond the initial focus on community planning and coordination, demonstration programs, and the training of personnel in gerontology, to provide supportive services to the elderly, such as in-home care for the frail elderly, nutritional services, and legal assistance. At the same time, the level of federal funding has not kept pace in real terms with this expanded mission (as we pointed out in a recent report\2 ). Further, as a result of budgetary constraints at state and local levels of government, the Aging Network is now under severe fiscal duress. Accordingly, service cutbacks are occurring, and other service curtailment options are being reviewed. In addition, structural changes have occurred, and others are being considered, such as a plan to cut the number of area agencies in Michigan from 14 to 7. Additional pressures from two other sources are constraining the Aging Network. First, there has been a significant increase in the number and proportion of the elderly in the United States, particularly those 85 and older. Second, many states, among them Oregon and Wisconsin, have assigned additional responsibilities to the Aging Network to administer programs beyond the scope of the Older Americans Act, such as administering the elderly component of Medicaid programs. It is in this context, that one must assess the current efforts of AOA. In April 1991, AOA launched a multiyear initiative, called the National Eldercare Campaign to augment the resources and capacities to provide supportive services to vulnerable, at-risk elderly in the United States.\3 -------------------- \2 See Administration on Aging: Harmonizing Growing Demands and Shrinking Resources (GAO/PEMD-92-7, Feb. 12, 1992). \3 Title IV of the Older Americans Act authorizes discretionary funding which the Administration on Aging (AOA) employs to support efforts in three areas: research, training, and demonstration. FINDINGS ON EVALUATION QUESTION 1: WHAT IS THE NATIONAL ELDERCARE CAMPAIGN? ------------------------------------------------------------ Letter :4 DESCRIPTION OF THE CAMPAIGN ---------------------------------------------------------- Letter :4.1 AOA launched the National Eldercare Campaign with three goals. These included (1) building coalitions among organizations in ways that will achieve a nationwide commitment to action; (2) raising public awareness and support through media outreach; and (3) encouraging organizations to adopt an eldercare agenda. To accomplish these goals, AOA adopted the following strategy: Project CARE sought to enlist state and local coalitions to identify the target population, their needs, and generate resources to meet their needs. Public Awareness Campaign was a multifaceted initiative using public service announcements, newspaper articles, videos, a magazine, brochures, and press kits to make the public aware of the needs of at-risk older persons. Outreach to National Organizations was designed to enlist the support of nonaging national organizations to promote an agenda that enhances community capacities to serve older persons at risk of losing their independence. Together, these three components were expected to raise public awareness of aging issues and generate additional resources to meet the needs of at-risk elderly persons. The largest amount of these funds ($4.8 million) was allocated to a new community outreach effort, Project CARE, which is a national coalition-building demonstration program. Since Project CARE and related support activity accounted for most of the funds allocated to this Campaign (60 percent in the first year, for example), as agreed with the Subcommittee staff, we focused our analytical attention most heavily on this component of the Campaign. PROJECT CARE -------------------------------------------------------- Letter :4.1.1 The intent of Project CARE was to demonstrate that coalitions that widen their base of support at the state and local levels can enhance a community's ability to provide needed services for an increasing population of aging persons who are at risk of losing their self-sufficiency. Project CARE was to recruit groups that have not traditionally focused on aging issues. They would provide new advocates, ideas, and approaches to mobilizing community resources. Project CARE had both mandatory and optional components. The three local coalitions per state were mandatory. The statewide coalitions and volunteer corps were optional. AOA aimed to fund 150 Project CARE local coalitions (3 in each state) through awards to the state units on aging and area agencies on aging. AOA envisioned that state units and area agencies would select three local coalitions dispersed across the state to represent an inner city neighborhood, a medium or small city, and a rural area. AOA further specified that "several of the selected communities should have a high concentration of older persons in greatest economic need, especially low-income minorities, including Native American elders."\4 The 42 state units on aging that have area agencies on aging received $100,000 each for fiscal year 1992 to start and maintain three local coalitions. These funds were distributed as follows: the state unit received $10,000, each of the three area agencies received $10,000, and each of the three lead organizations for the local coalitions received $20,000. (AOA anticipated that this funding would remain constant for each year of the 3-year pilot.) These funds were used largely to retain a part-time person to coordinate efforts among the units involved (that is, the state unit, the area agency, and the lead organization) and for administrative costs supporting coalition activities. For the remaining 8 states with no area agencies on aging (Rhode Island, New Hampshire, Delaware, North Dakota, South Dakota, Wyoming, Nevada, and Alaska), each state unit received $15,000, and each of the three coalitions was allocated $20,000 annually. -------------------- \4 See Department of Health and Human Services, "Program Instructions," AOA-P1-06, p. 8. PUBLIC AWARENESS CAMPAIGN -------------------------------------------------------- Letter :4.1.2 In its first year, the National Eldercare Campaign sought to expand public awareness at the national, state, and local community levels. AOA officials told us that through the collective efforts of the components of the Campaign (Project CARE, Public Awareness, and Outreach), various public information activities were undertaken in the first year. At the national level, the following examples of products were developed to build awareness: a variety of posters, information kits, brochures, and exhibits for public use, and a new quarterly magazine, Eldercare Today, which highlights the accomplishments of the Campaign. AOA officials could not tell us who the various target audiences were. OUTREACH TO NATIONAL ORGANIZATIONS -------------------------------------------------------- Letter :4.1.3 For the period October 1, 1991-February 28, 1993, AOA allocated $1.8 million to support outreach activities to 18 national organizations. (Each organization received about $100,000.) This effort was designed to build the awareness and commitment of national and regional organizations to an agenda that will, in turn, enhance community capacities to serve older persons at risk of losing their independence. Our review of agency documents suggests that AOA was successful in recruiting many national organizations that were not previously committed to aging issues. Twelve of the 18 awardees were nonaging organizations; the remaining 6 were organizations that focused on the elderly (see table 2). Table 2 Participating National Organizations, Fiscal Year 1992 Principal Organization focus ------------------------------------------------ ---------- American Bar Association Nonaging American Institute of Architects/Association of Nonaging Collegiate Students of Architecture American Medical Association Nonaging American Red Cross Nonaging American Society on Aging Aging Asociacion Nacional Pro Personas Mayores Aging Catholic Charities USA Nonaging Health Insurance Association of America Nonaging National Association of Counties Nonaging National Association of Social Workers Nonaging National Black Caucus of State Legislators Nonaging National Caucus and Center on Black Aged Aging National Hispanic Council on Aging Aging National Council of Negro Women Nonaging National Easter Seal Society Nonaging National Title VI Directors Associations Aging Public Health Foundation Nonaging SOS (Save Our Social Security) Education Fund Aging ------------------------------------------------------------ Source: AOA. AOA officials told us that each of the 18 organizations had started to work on a project tailored to its particular interest. For example, the American Bar Association, in the first year, started to develop an educational program to help social workers and religious organizations become more informed about legal issues critical to at-risk elderly persons. The American Medical Association sponsored a project to increase the awareness of physicians of the role that community resources play in geriatric care. AOA officials, however, could not tell us whether these organizations succeeded in reaching their targeted audiences. SUPPORT ACTIVITIES ---------------------------------------------------------- Letter :4.2 NATIONAL ELDERCARE INSTITUTES -------------------------------------------------------- Letter :4.2.1 To support the activities of Project CARE, AOA obligated approximately $3.55 million for 13 Eldercare Institutes in fiscal year 1992 to help the local coalitions mobilize community participation and develop effective service initiatives. The purpose of these institutes was to analyze important issues related to eldercare; provide training and technical assistance to state units, area agencies and local coalitions; and serve as a resource to organizations involved in the Campaign. The 13 Institutes were specified by subject area, including long-term care, elder abuse, transportation, and so on (see table 3). Each of the Institutes received from $250,000 to $329,000 for the first year of operation. These Institutes replaced the former National Resource Centers. Table 3 Eldercare Institutes and Sponsors Institute Sole Grantee or Lead Organization --------------------------------------- --------------------------------------- Income security Families USA Employment and volunteerism Center on Aging, University of Maryland Housing and supportive services Ethel Percy Andrus Gerontology Center, University of Southern California Transportation Community Transportation Association of America Multipurpose senior centers and National Council on Aging community focal points Health promotion and aging American Association of Retired Persons Nutrition National Association of Nutrition and Aging Services Programs Long-term care National Association of State Units on Aging Long-term care and Alzheimer's disease Suncoast Gerontology Center, University of South Florida Elder abuse and state long-term care National Association of State Units on ombudsman services Aging Older women National Council of Negro Women Human resources Brookdale Center on Aging, Hunter College Business and aging Washington Business Group on Health -------------------------------------------------------------------------------- Source: AOA, Compendium of Active Grants Under Title IV of the Older Americans Act (Washington, D.C.: October 1992). ELDERCARE CONNECTIONS -------------------------------------------------------- Letter :4.2.2 Eldercare Connections was to provide participating organizations access to a comprehensive repository of information concerning the Eldercare Campaign and summary information about products produced for the Campaign. In addition, the project was funded to publish and distribute a bimonthly update of all products received, maintain a computerized bulletin board for quick access to information in the database, and publish and distribute a calendar of events of important eldercare meetings around the country. In fiscal year 1992, this activity was funded by AOA for $156,700. ELDERCARE LOCATOR -------------------------------------------------------- Letter :4.2.3 The Eldercare Locator project, which predated the Campaign, was a collaborative effort among AOA, National Association of Area Agencies on Aging, and National Association of State Units on Aging. The purpose of this project was to establish a national 800 (toll-free) number to assist families and friends in finding information about community services for older persons and help identify the most appropriate organizations to call for help. The Eldercare Locator is now in operation. This activity was begun in fiscal year 1990, with funding at $311,300 in that year, $403,700 in fiscal year 1991, and $473,500 in fiscal year 1992. FINDINGS ON EVALUATION QUESTION 2: WHAT HAS BEEN THE PROGRESS, THUS FAR, IN IMPLEMENTING THE CAMPAIGN? ------------------------------------------------------------ Letter :5 STATUS OF IMPLEMENTATION ---------------------------------------------------------- Letter :5.1 At the time of our data collection (spring 1993), all components of the Campaign (Project CARE, Public Awareness, and Outreach) were in place and operating nationwide. AOA urged state units on aging, to the extent possible, to develop new coalitions and diversify the location of the three mandatory ones to have one in an inner city neighborhood of a large city, one in a medium or small city, and one in a rural area. We found, however, that the local coalitions operated somewhat differently than expected, based on the above description, in two ways. First, we found that 24 percent of respondents to our survey described their coalitions as having existed prior to the National Eldercare Campaign. We do not know whether area agencies simply were not successful in recruiting "nontraditional" organizations or whether they made a decision not to recruit these organizations. Second, we found that coalition locations did not match program guidelines: inner city, small city, and rural area. The coalitions tended to be in smaller places; half of them in areas with a population of 20,000 or less. Many area agencies located in very large cities--in New York and California, for example--did not even apply for funding. They may have already expanded their base of support, or a $10,000 grant may not have been large enough for them to apply. In the first year, AOA expected the local coalitions to select a target population of vulnerable, at-risk older persons, identify a need, select a service, generate resources to support that project, and develop a project that delivers the service to meet the need. AOA officials provided information indicating that, at the end of the first year, approximately 80 percent of the coalitions had identified a target population and a need and had selected a priority service. GENERATION OF RESOURCES AND SERVICES ---------------------------------------------------------- Letter :5.2 With regard to the generation of resources, a majority of coalitions responding to our survey reported generating the following types of resources: funds (63 percent), services-in-kind (75 percent), donations of materials (55 percent), and volunteer labor (71 percent). The level of funds being generated was relatively low (only 14 percent obtained amounts over $10,000); however, among those not raising funds to date were a small number of coalitions (fewer than a dozen) that were incorporating so as to facilitate their fund-raising. Finally, based on our survey results, we found that 71 percent of the coalitions (107 of 151) are providing a service. About half of those coalitions providing a service (56 of 107) are delivering one and only one service; but the rest (51 out of 107) are delivering two or more services. For those coalitions not providing services (44 out of 151), the state unit officials reported four reasons why those coalitions were slow in organizing and delivering a service: (1) turnover or illness of the part-time local coalition coordinator; (2) lack of necessary organizational or needs assessment skills of the local coordinator; (3) insufficient support from the local coalition lead organization, and (4) slowness on the part of the state in processing the necessary papers, inhibiting the rapid flow of funds to the area agencies and local coalitions. We found that the coalitions were providing four major categories of services. First, 56 coalitions were delivering access to services, providing information and referral, transportation, outreach activities, and the publication and distribution of service directories. Second, 30 coalitions were providing in-home services, providing housekeeping and other chores, grocery and errand services, telephone reassurance, and visits to the homebound. Third, 22 coalitions were providing housing repair and maintenance activities, including the installation of ramps for facilitating the access of wheelchair users as well as outdoor security lights. Finally, 21 coalitions were delivering health, nutrition, and meal services, including eye and ear screening, wellness clinics, and publications (see table 4). Table 4 Most Frequent Services Provided by Project CARE Local Coalitions\a Type of service Number Percent ---------------------------------------- -------- -------- Access 56 27 Information and referral 17 Transportation 13 Outreach 11 Service directories 10 Miscellaneous 5 In-home service 30 14 Housekeeping chores 9 Telephone reassurance 5 Visiting homebound 5 Grocery shopping and errands 4 Miscellaneous 7 Housing and related services 22 11 Repair and maintenance 12 Miscellaneous 10 Health, nutrition, and meals 21 10 Meals 7 Health screening 4 Wellness 3 Miscellaneous 7 Other\b 80 38 ============================================================ Grand total 209 100 ------------------------------------------------------------ \a A preliminary estimate as of December 31, 1992. \b Includes, for example, services focusing on education, recreation, crisis intervention, seasonal activities, public safety, among others. FINDINGS ON EVALUATION QUESTION 3: WHAT CHANGES IN THE AGING NETWORK ARE DISCERNIBLE AT THIS TIME? ------------------------------------------------------------ Letter :6 CHANGE IN MISSION AND STRUCTURE OF THE AGING NETWORK ---------------------------------------------------------- Letter :6.1 Recognizing that OAA resources were never going to be sufficient to meet the service needs of all elderly persons, the Congress envisioned that AOA would serve as an effective and visible advocate for the elderly. In this role, AOA would coordinate and assist local public and private entities in planning and implementing community services for the elderly. However, AOA never allocated any money specifically to implement this aspect of their function. In the past, AOA title IV initiatives have consisted of 12- to 24-month projects to provide research and demonstration programs and technical assistance to the Aging Network. By launching the National Eldercare Campaign, AOA made a substantial, multiyear commitment to implement a formal mechanism to broaden the base of the Aging Network. The National Eldercare Campaign is a creative effort to expand the structure of the Aging Network to include new coalitions and national organizations that were traditionally not primarily involved in aging issues. About 200 coalitions were established in year 1 as part of the Aging Network, and their function is not only to serve as advocates for the elderly, but also to work on developing programs for older individuals. In addition, AOA reorganized and redirected the focus of the Institutes to provide support specifically to strengthen the coalitions, organizations, and other components of the Campaign. This, then, is a significant change in both the mission and the structure of the Aging Network. One effect of the Campaign on the expansion of the Aging Network is that in the first year, the coalitions have started to generate new resources. Whether they will be able to sustain themselves beyond the 3-year funding level is too early to tell. SUMMARY ---------------------------------------------------------- Letter :6.2 In summary, the National Eldercare Campaign is designed to broaden the impact of the Older Americans Act, which calls for community involvement in meeting the needs of the elderly population, especially those with greatest economic and social needs, including low-income minorities. By setting aside a critical mass of funding for this purpose (about $14 million of the $26 million total title IV discretionary funds), AOA has succeeded in expanding the Aging Network and thereby is enhancing local level capabilities to organize and deliver services to meet the needs of at-risk elderly. AGENCY COMMENTS ------------------------------------------------------------ Letter :7 We requested written comments from officials of the Administration on Aging, but none were provided. We did obtain their views during an exit conference. They were in general agreement with our findings. We are sending copies of this report to the Secretary of Health and Human Services, the Assistant Secretary for Aging, and others. We will also send copies to interested parties upon request. If you have any questions or would like additional information, please call me at (202) 512-2900 or Robert L. York, Director of Program Evaluation in Human Services Areas, at (202) 512-5885. Other major contributors to this report are listed in the appendix. Sincerely yours, Eleanor Chelimsky Assistant Comptroller General MAJOR CONTRIBUTORS TO THIS REPORT ==================================================== Appendix Appendix PROGRAM EVALUATION AND METHODOLOGY DIVISION -------------------------------------------------- Appendix Appendix:1 Sushil K. Sharma, Assistant Director Harold C. Wallach, Project Manager Brian Keenan, Survey Methodologist Venkareddy Chennareddy, Senior Economist Elaine Vaurio, Project Staff